Autistic women and girls are masking to such a degree that they risk late or missed diagnosis. Masking may help socially and professionally in the short term, but may also harm mental health and a person’s sense of self-worth in the process.
What is masking? Masking or camouflaging is artificially performing social behavior that is deemed to be more socially acceptable (by neurotypical standards) or hiding behavior that might be viewed as socially unacceptable (1). The motivations for masking autistic traits are largely socially motivated - including avoiding negative social consequences like bullying, as well as increasing connections with others, success at work, and success in relationships. Masking itself consists of a combination of camouflaging and compensation techniques where a person works to control impulses, act ‘neurotypical’, rehearse answers to questions or conversations, and mimic others. In short, masking involves suppressing certain parts of oneself and performing other behaviors. The short- and long-term consequences of masking include exhaustion, negative mental health effects, and a deterioration of one’s sense of self (5, 2, 7).
Over the years, the reported ratio of those who have received an autism diagnosis is 1 woman or girl to every 4-5 boys or men* (3). This diagnostic imbalance likely has a variety of causes. One of which may be biological sex differences, but another reason that is strongly supported by current research, may be due to under- or mis-recognition of autism in women. Academic research on autism has predominantly been carried out with male participants thus making the behavior and characteristics of autism gender stereotypical with a male-based behavioural characterization of autism. Recent research suggests that women on the autistic spectrum have a higher likelihood of subtler behavioral presentation than their male counterparts. “Behavioural observations suggest that girls camouflage their social difficulties (e.g. by staying in close proximity to peers and weaving in and out of activities) to a greater extent on the playground than boys, and therefore are less likely to be identified as struggling socially” (2). This is likely one of the reasons that women or girls tend to be underdiagnosed; they may ‘fly under the radar’ due to the insufficient knowledge of gendered behavioral characteristics of autism.
*This particular study did not consider non-binary or gender diverse people. This is a huge gap, especially considering the higher likelihood of members of the autistic community being gender diverse.
Autistic women and girls may, as mentioned, be better at ‘camouflaging’ or ‘masking’ their symptoms, while displaying subtler characteristic behavioral presentation than men and boys (1). Anecdotal clinical and autobiographical observations suggest that women show more social interest, heightened emotional or affective empathy, increased imagination, better masking of social difficulties, different contents of narrow interests, and more friendships than autistic men (3).
##‘Neurotypical’ interaction and its consequences The motivation for masking was found to be foremost the desire to fit in and create connections with others (6, 2). Masking can contribute to achieving socially desirable outcomes such as making friends, improving social status, and performing better in job interviews (2). Camouflaging or using social imitation strategies includes imitations like “making eye contact during conversation, using learned phrases or pre-prepared jokes in conversation, mimicking other’s social behaviour, imitating facial expressions or gestures, and learning and following social scripts” (1). These masking or compensation strategies are often very exhausting and come at a cost. Masking requires a substantial cognitive effort (6), which can be exhausting and may lead to “increased stress responses, meltdown due to social overload, anxiety and depression, and even a negative impact on the development of one’s identity” (1).
The demands of masking may be one reason that it’s been demonstrated that autistic women are more likely to experience internalised challenges, like anxiety and depression, than men who are more likely to have external difficulties, such as hyperactivity and behavioral challenges. Additionally, studies indicate that females are more likely than males to receive a misdiagnosis of other mental health conditions, such as personality disorders or eating disorders. Yet another reason why masking and social imitation strategies may lead to either missed or late diagnoses (2).
Late-diagnosed individuals tend to suffer from concurrent mental health challenges, potentially related to long-term stress due to social overload in adaptation to daily life in neurotypical-centered society (1). Autobiographical observations and interviews with women, who have been diagnosed later in life indicate many women who have compensated and spent their whole lives feeling different until their children receive a diagnosis that they recognize themselves in (2).
With the new ICD-11, the measures used to assess ASC have been changed and sectioned into six distinctive expressions that now enable specialists to assess challenges and traits individually. Late diagnostic practices focused on the core ASC characteristics that were established based largely from behavioural presentation in males may not reflect upon the female behavioural presentation, resulting in the overlooking of those who did not meet the male-typical behavioural presentation (2).
Masking is not a beneficial behavior in the long run and scientists now echo what autistic advocates have been saying for decades: that it should not be encouraged for people diagnosed with ASC, as masking poses a serious threat to mental health, wellbeing and development of identity. The reality is that ‘(f)or many autistic people, camouflaging is experienced as an obligation, rather than a choice. It is often motivated by a sense of alienation and threat, and frequently represents an attempt to avoid ostracism and attacks’ (2019).
Although masking has predominantly been described in relation to autistic women and girls, studies have reported that masking is not a gender-specific phenomenon(5). More studies and research on masking are so needed in order to better understand the long-term impacts on the wellbeing of individuals who mask and how we can create societies that allow people to be their authentic selves (2).
Lai, M., Lombardo M. V., Ruigrok, A. N.V., Chakrabarti, B., Auyeung, B., Szatmari, P., . Baron-Cohen, S. (2016). Quantifying and exploring camouflaging in men and women with autism. Retrieved from https://journals.sagepub.com/doi/pdf/10.1177/1362361316671012.
Hull, L., Petrides, K. V., Allison, C., Smith, P., Baron‑Cohen, S., Lai, M. & Mandy W. (2017). “Putting on My Best Normal”: Social Camouflaging in Adults with Autism Spectrum Conditions. Retrieved from https://link.springer.com/content/pdf/10.1007%2Fs10803-017-3166-5.pdf.
Lai, M., Ameis, S. H. & Szatmari, P. (2017) Adolescents with Autism Spectrum Disorder: A Clinical Handbook. Retrieved from http://www.oxfordclinicalpsych.com/view/10.1093/med-psych/9780190624828.001.0001/med-9780190624828-chapter-12?print=pdf.
Baron-Cohen, S. (2017). The Genetics of Autism, Autism Research Centre. Retrieved from http://docs.autismresearchcentre.com/papers/2017_Warrier_The-Genetics-of-Autism.pdf.
Hull, L., Lai, M.-C., Baron-Cohen, S., Allison, C., Smith, P., Petrides, K., & Mandy, W. (2020). Gender differences in self-reported camouflaging in autistic and non-autistic adults. Autism, 24(2), 352–363.
Cage, E., Troxell-Whitman, Z. (2019). Understanding the reasons, contexts and costs of camouflaging for autistic adults. Journal of Autism and Developmental Disorders, 49, 1899–1911.
Cage E, Di Monaco J, Newell V. Experiences of Autism Acceptance and Mental Health in Autistic Adults. J Autism Dev Disord. 2018;48(2):473‐484. doi:10.1007/s10803-017-3342-7